Pennsylvania's bright pink order sheet recording a seriously ill or frail patient's choices on CPR, medical interventions, antibiotics and artificially administered hydration and nutrition. It is meant for patients whose clinicians would not be surprised if they died within a year. A physician, PA or CRNP completes it with the patient or surrogate, and it travels with the patient between hospitals, nursing homes, assisted living facilities and other care settings.
A health care professional prepares the form from the patient's preferences and medical indications, and a physician, physician assistant or certified registered nurse practitioner signs Section E. The patient or surrogate (health care agent, health care representative, court-appointed guardian or parent of a minor) also signs; both signatures are required for the form to be valid.
Enter the patient's last name, first name and middle initial, and date of birth. The header instructs responders to follow the orders first and then contact the physician, CRNP or PA, and notes that an EMS provider needs an order from a medical command physician to follow the form. 'Send form with person whenever transferred or discharged' is printed at the top of both pages.
Applies when the person has no pulse and is not breathing. Check one: CPR/Attempt Resuscitation, or DNR/Do Not Attempt Resuscitation (Allow Natural Death). When the person is not in cardiopulmonary arrest, Sections B, C and D apply. The directions note an AED should not be used on a person who has chosen Do Not Attempt Resuscitation.
Applies when the person has a pulse or is breathing. Check one: Comfort Measures Only (no transfer for life-sustaining treatment unless comfort needs cannot be met), Limited Additional Interventions (IV fluids, cardiac monitor, no intubation or mechanical ventilation, avoid intensive care if possible) or Full Treatment (intubation, ventilation, cardioversion, intensive care). An Additional Orders line follows.
Check one: no antibiotics, using other measures to relieve symptoms; determine use or limitation of antibiotics when infection occurs, with comfort as the goal; or use antibiotics if life can be prolonged. Add any specifics on the Additional Orders line.
Food and liquids by mouth are always offered if feasible. Check one: no hydration and artificial nutrition by tube, a trial period of artificial hydration and nutrition by tube, or long-term artificial hydration and nutrition by tube. Use the Additional Orders line for details such as the length of a trial.
Check who the orders were discussed with (patient, parent of minor, health care agent, health care representative, court-appointed guardian or other) and summarize the patient's goals and medical condition. The physician, PA or CRNP prints their name and phone number, signs (required) and dates. The patient or surrogate signs (required), prints their name and states the relationship, writing 'self' if the patient signs.
List the surrogate's name, relationship and phone number, and the health care professional who prepared the form with title, phone and date prepared. Page 2 also carries the directions for completing, using, reviewing and revoking the POLST, so print both pages together.
Download the current version from the source each time; forms change without notice.
The Pennsylvania Orders for Life-Sustaining Treatment (POLST) Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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A physician, physician assistant or certified registered nurse practitioner signs as the practitioner, and the patient or surrogate signs too; both are required. Verbal orders are acceptable with a follow-up practitioner signature under facility or community policy. By contrast, Pennsylvania's Out-of-Hospital DNR order requires the attending physician's signature.
Not on its own. The form states that an EMS provider needs an order from a medical command physician to follow it, and under protocol only the Out-of-Hospital DNR order lets EMS withhold CPR immediately. The pink POLST can still simplify the conversation with medical command about stopping resuscitation, and the form directs practitioners to discuss an Out-of-Hospital DNR order with eligible patients who choose DNR.
The Pennsylvania POLST Coalition asks that the form be printed on Pulsar Pink 65# card stock so it is distinctive and recognizable across the state. The directions encourage use of the original pink form, while photocopies and faxes of a signed POLST should still be respected where necessary.